Manager, Provider Dispute and Appeals

Location: Remote - FL, Florida US

Notice

This position is no longer open.

Job Number: 3190

Position Title: Manager, Provider Dispute and Appeals

External Description:

Alignment Healthcare is seeking an experienced Provider Dispute and Appeals Manager.

Do you have provider dispute AND provider appeals experience? If so, we want to speak with you!

****SIGN-ON BONUS AVAILABLE****

****SEEKING CANDIDATES IN CALIFORNIA, NEVADA OR ARIZONA****

Alignment Healthcare was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time.

By becoming a part of the Alignment Healthcare team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community.

Position Summary: 

The Manager, Provider Dispute and Appeals is responsible for the overall compliance which include timely and accurate resolutions of provider disputes and provider payment appeals. The Manager is responsible for the daily management or supervision of staff performing provider disputes and provider appeals resolution. The Manager is responsible for the daily monitoring of inventory and accurate reporting. The Manager is responsible for implementing appropriate controls, development and implementation of policies and procedures, training programs and performing root cause analysis and risk assessments to maintain compliance in resolving provider disputes and provider appeals for payments.

 General Duties/Responsibilities:

(May include but are not limited to) 

· Manages the day-to-day operations and processes related to provider disputes, provider appeals and other related provider inquiries.

· Develops department metrics and performance standards; assists team in meeting or exceeding departmental performance standards.

· Distribute work assignments among staff and ensure timely and accurate processing of assigned tasks.

· Monitors daily inventory. Ensure all receipts and completed provider disputes and appeals are accurately reported. Immediately report and resolve any potential issues related to inventory and/or reporting.

· Monitors timely and accurate resolution of provider appeals and provider disputes.

· Monitors staff production and work quality. Ensure staff fully understands expectations.

· Ensure internal and external communications are clear, concise and accurate by conducting quality reviews.

· Provides direct support and leadership to staff performing provider appeals and dispute resolution.

· Conducts root-cause analyses, identifies opportunities for improvement and recommends solutions

· Collaborate with other departments to ensure timely and accurate resolution of payment disputes, provider appeals and timely resolution of member requests for payments.

· Develops and maintains department’s policies and procedures, workflows, letters and training documents; conducts regular trainings.

· Ensures compliance with policies, procedures and practices.

· Facilitates training and team development to enhance the knowledge and skills of the team members.

· Assists team in meeting or exceeding departmental performance standards.

· Conducts regular meetings with staff (department meetings and one-on-one) to ensure both departmental and individual performance are met.

· Assists in resolution of more complex cases.

· Acts as the subject matter expert to assist with regulatory audits, as required as well as prepare materials required for regulatory audit submission.

· Maintains compliance in all areas of provider dispute and appeals resolution, which include timely and accurate submission of regulatory reports.

· Stays abreast on all regulatory and/or contractual changes and communicates changes to staff

· Performs additional related duties as assigned.

Supervisory Responsibilities:

Oversees assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees. 

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

1. Minimum Experience:

a. 3-5 years management experience in provider dispute and provider appeals resolutions, Medicare managed care or health plan setting; or

b. 5+ years experience in Medicare medical claims management in managed care setting

 2. Education/Licensure:

Bachelor’s degree in healthcare management or related field; and/or equivalent experience

3. Other:

a. Extensive knowledge of Medicare Managed Care organization determination, appeals and grievance requirements, specifically reconsideration and IRE submission requirements

b. Comprehensive knowledge of Medicare ODAG and Part C reporting.

c. Strong knowledge of professional and institutional claims

d. Knowledge of claims processing systems (EZCAP preferred) and claims audit tools

e. Intermediate to Advance proficiency in MS Office products – Word, Access and Excel

f. Comprehensive knowledge of Medicare Advantage claims processing requirements and other related regulatory requirements

g. Working knowledge of different claims coding requirements and payment methodology (PPS, Medicare fee schedules, etc.)

h. Ability to provide reporting requirements based on processes and/or regulatory requirements

i. Knowledge of medical terminology

j. Proven problem-solving skills and ability to translate knowledge to the department

k. Strong organizational skills and decision-making and attention to details

l. Ability to work well in a fast-paced and dynamic environment.

m. Excellent presentation and training skills; group motivation and supervisory skills.

Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.

If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact careers@ahcusa.com.

City: Remote - FL

State: Florida

Location City: Remote - FL

Location State: Florida

Community / Marketing Title: Manager, Provider Dispute and Appeals

Company Profile:

Alignment Healthcare was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time.

By becoming a part of the Alignment Healthcare team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community.

EEO Employer Verbiage:

Alignment has implemented a policy requiring all new hires to receive the COVID-19 vaccine and booster.  Proof of vaccination and booster will be required as a condition of employment subject to applicable laws concerning exemptions/accommodations.  This policy is part of Alignment’s ongoing efforts to ensure the safety and well-being of its staff and community, and to support public health efforts.

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.

If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact careers@ahcusa.com.